Diagnosis and Management of an Enlarging Placental Immature Teratoma: A Case Report

The clinical imaging and pathology of a rare case of immature teratoma of the placenta is presented with a discussion of controversies related to classification and clinical suggestions for therapy and follow-up.

Predictors of Tumor Dynamics during a 6-Week Course of Chemoradiotherapy for Glioblastoma

PURPOSE/OBJECTIVE(S)

Our prior imaging studies have shown geometrically meaningful inter-fraction tumor dynamics specific to glioblastoma (GBM). We aim to identify predictors associated with tumor dynamics during a 6-week course of concurrent chemoradiotherapy (CRT) for GBM.

MATERIALS/METHODS

Patients enrolled in a prospective serial magnetic resonance imaging (MRI) study were reviewed. All patients were treated with 54-60 Gy in 30 fractions. The gross tumor volume (GTV) included the surgical cavity and T1c enhanced residual tumor; clinical tumor volume (CTV) included GTV with a 15mm isotropic expansion, respecting anatomical boundaries; planning target volume (PTV) was 4mm expansion. MRIs were obtained at RT planning (F0), fraction 10 (F10), and fraction 20 (F20). Tumor dynamic metrics (relative to F0) assessed included the GTV volume (Vrel), Hausdorff distance (dH) and migration distance (dM). dH is the average distance between two datasets in metric space. dM is the maximum linear displacement of the GTV in any direction. Factors to be determined associated with tumor dynamics included: age, sex, corpus callosum (CC) involvement, extent of surgery (gross total resection (GTR), subtotal resection (STR) or biopsy alone (Bx)), MGMT methylation and IDH mutation status.

RESULTS

A total of 129 patients were reviewed. Median GTV was 20.9cc at F0, 17.6cc at F10 (Vrel 0.85), and 16.1cc at F20 (Vrel 0.78). Patients without CC involvement had more marked GTV volume reduction: Vrel 0.82 vs 1.02 with CC involvement at F10 (P = 0.05), and Vrel 0.77 vs 0.88 with CC involvement at F20 (P = 0.03). Patients with GTR (vs STR vs Bx) had more marked GTV volume reduction across all time points: Vrel 0.78, 0.85 and 1.07 respectively at F10 (P = 0.001), and Vrel 0.69, 0.80, 1.04 respectively at F20 (P = 0.001). The median dH was 8.1mm at F10 and 9.2mm at F20. Patients with CC involvement (vs without CC involvement) had a larger dH: 54% vs 25% had dH>10mm respectively at F10 (P = 0.03), and 73% vs 28% had dH>10mm respectively at F20 (P<0.005). Patients with a GTR had smaller dH at both F10 (P = 0.02) and F20 (P = 0.006). At F20, 20%, 47% and 37% of patients with GTR, STR and Bx had dH>10mm (P = 0.04). The median dM were 4.7mm at F10 and 4.7mm at F20. Patients with CC involvement (vs without CC involvement) had larger dM: 41% vs 12% had dM >10mm respectively at F10 (P = 0.01), and 45% vs 9% had dM >10mm respectively at F20 (P<0.001). Patients with GTR had smaller dM at F10 (P = 0.03) and F20 (P0.002). At F20, 0%, 25% and 19% of patients with GTR, STR and Bx had dM>10mm (P = 0.002). Age, sex, MGMT methylation and IDH mutation status were not associated with Vrel, dH and dM at F10 and F20.

CONCLUSION

We identified CC involvement and extent of surgery to be associated with tumor dynamics at F10 and F20 over the course of CRT for GBM. This offers opportunities to better select patients who may benefit from earlier/ more frequent RT replan/ adaptation to ensure adequate tumor coverage, or to reduce RT toxicities.

Genetic Variations in TrkB.T1 Isoform and Their Association with Somatic and Psychological Symptoms in Individuals with IBS

Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, is often comorbid with somatic pain and psychological disorders. Dysregulated signaling of brain-derived neurotrophic factor (BDNF) and its receptor, tropomyosin-related kinase B (TrkB), has been implicated in somatic-psychological symptoms in individuals with IBS. Thus, we investigated the association of 10 single nucleotide polymorphisms (SNPs) in the regulatory 3' untranslated region (UTR) of NTRK2 (TrkB) kinase domain-deficient truncated isoform (TrkB.T1) and the BDNF Val66Met SNP with somatic and psychological symptoms and quality of life in a U.S. cohort (IBS n=464; healthy controls n=156). We found that the homozygous recessive genotype (G/G) of rs2013566 in individuals with IBS is associated with worsened somatic symptoms, including headache, back pain, joint pain, muscle pain, and somatization as well as diminished sleep quality, energy level and overall quality of life. Validation using U.K. BioBank (UKBB) data confirmed the association of rs2013566 with increased likelihood of headache. Several SNPs (rs1627784, rs1624327, rs1147198) showed significant associations with muscle pain in our U.S. cohort. Notably, these SNPs are predominantly located in H3K4Me1-enriched regions, suggesting their enhancer and/or transcription regulation potential. Together, our findings suggest that genetic variation within the 3'UTR region of the TrkB.T1 isoform may contribute to comorbid conditions in individuals with IBS, resulting in a spectrum of somatic and psychological symptoms that may influence their quality of life. These findings advance our understanding of the genetic interaction between BDNF/TrkB pathways and somatic-psychological symptoms in IBS, highlighting the importance of further exploring this interaction for potential clinical applications.

Competition Anxiety in Combat Sports and the Importance of Mental Toughness

Combat sports require participants to engage in potentially dangerous forms of contact-based competition. Pressure to succeed, coupled with the risk of severe injury can induce significant levels of anxiety, which if uncontrolled, can negatively impact performance and possibly promote unsporting conduct. The present study examined competitive anxiety levels of combat sports athletes and determined whether self-reported scores were associated with mental toughness and Sportspersonship attitudes. A cross-sectional survey design was used whereby participants (N = 194) completed a battery of questionnaires measuring competitive combat sport experiences, demographic details, Sportspersonship traits (compliance towards rules, respect for opponents, and game perspective), and competition anxiety (somatic, cognitive, and self-confidence; reported retrospectively). Results suggest that mentally tough athletes experience lower levels of cognitive and somatic anxiety, and higher self-confidence, prior to competitions. Findings also found that athletes endorsing more altruistic and respectful attitudes in sport (Sportspersonship) reported higher levels of competition anxiety. The findings demonstrate that mental toughness is allied to positive attributes and could potentially be operationalized to improve both the retention and performance of combat sports athletes. Thus, the authors advocate the use of mental toughness coaching interventions within combat sports.

Expert consensus recommendations for the provision of infective endocarditis services: updated guidance from the Joint British Societies

Infective endocarditis (IE) remains a difficult condition to diagnose and treat and is an infection of high consequence for patients, causing long hospital stays, life-changing complications and high mortality. A new multidisciplinary, multiprofessional, British Society for Antimicrobial Chemotherapy (BSAC)-ledWorking Party was convened to undertake a focused systematical review of the literature and to update the previous BSAC guidelines relating delivery of services for patients with IE. A scoping exercise identified new questions concerning optimal delivery of care, and the systematic review identified 16 231 papers of which 20 met the inclusion criteria. Recommendations relating to endocarditis teams, infrastructure and support, endocarditis referral processes, patient follow-up and patient information, and governance are made as well as research recommendations. This is a report of a joint Working Party of the BSAC, British Cardiovascular Society, British Heart Valve Society, British Society of Echocardiography, Society of Cardiothoracic Surgeons of Great Britain and Ireland, British Congenital Cardiac Association and British Infection Association.

Bacterial contamination of endoscopist and assistant face visors during gastrointestinal endoscopy: a pilot study

Background and aim

During the COVID-19 pandemic, health workers' facial exposure to pathogens has been brought into focus. In this study, we aimed to determine the occurrence and degree of facial contamination to both endoscopists and their assistants during endoscopic procedures to help inform future safety measures.

Methods

Non-sterile visors worn by endoscopist, assistant and room control visors from 50 procedures were swabbed post procedure for culture. Procedure type, therapy, duration and evidence of visible visor contamination were recorded. After 48-hour incubation, all bacterial colonies were identified using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. Organisms were classified into skin/environmental, oronasal and enteric.

Results

A total of 104 visors were available for assessment (93 staff; 11 control). In worn visors, skin/environmental flora were isolated from 70, oronasal flora from 8, and enteric flora from 3 with an average colony count of >9.5. Notably, bacteria of enteric origin (Escherichia coli and Enterobacter cloacae) were isolated from three worn visors. In room control, skin/environmental flora were isolated from seven and oronasal flora from one with average colony count of five. No room control visors grew enteric flora. Overall, 9.1% room control and 10.8% worn visors were contaminated with organisms that could possibly have originated from patients. However, enteric flora were only obtained from worn visors. No visors were visibly contaminated.

Conclusion

This pilot study demonstrates risk of contamination to faces of endoscopists and assistants. Larger studies are required to determine degree of risk and to give guidance on facial protection during gastrointestinal endoscopy.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Malocclusion severity and smile features: Is there an association?

INTRODUCTION

This observational study investigated the relationship between malocclusion and smiling.

METHODS

Adolescents and young adults (n = 72; aged 16-25 years) were identified according to their Dental Aesthetic Index (DAI) and allocated to 3 groups: (1) malocclusion group (n = 24; DAI ≥31), (2) retention group (n = 24; pretreatment DAI ≥31) with a prior malocclusion that had been corrected by orthodontic treatment, (3) control group with no-to-minor malocclusion (n = 24; DAI ≤25). Participants were requested to watch an amusing video. Based on the Facial Action Coding System, automated pattern recognition was used to detect smile episodes and assess their frequency, duration, genuineness, intensity, and extent of tooth show. Demographics, Big Five personality dimensions, and self-perceived smile esthetics-related quality of life were collected from all participants via questionnaires. Data were analyzed by mixed-model analysis and adjusted for possible confounders.

RESULTS

Patients from the malocclusion and retention groups smiled significantly less than participants from the control group, with the duration of smiles and smiling time being around half those of control subjects. Smile genuineness, smile intensity, and teeth shown did not differ across groups. Personality traits did not differ significantly among the 3 groups, whereas the malocclusion group scored around 30% less for dental self-confidence than the other 2 groups.

CONCLUSIONS

Patients with severe malocclusion tend to smile less, but the features of their smiles are similar to those without malocclusion. A lower propensity to smile in patients with a corrected malocclusion may persist after orthodontic treatment.

Impact of worsening surgically induced chronic kidney disease (CKD-S) in preoperative CKD-naïve patients on survival in renal cell carcinoma

OBJECTIVES

To evaluate effects of worsening surgically induced chronic kidney disease (CKD-S) on oncological and non-oncological survival outcomes in renal cell carcinoma (RCC).

PATIENTS AND METHODS

We performed a retrospective analysis of patients who underwent partial (PN) or radical nephrectomy (RN) and were free of preoperative CKD (estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m² ). Patients were stratified by CKD stage at last follow-up: no CKD-S (eGFR ≥60 mL/min/1.73 m² ), de novo CKD-S 3a (eGFR 45-59 mL/min/1.73 m² ), CKD-S 3b (eGFR <45 and ≥30 mL/min/1.73 m² ) and CKD-S 4 (eGFR <30 and ≥15 mL/min/1.73 m² ). The primary outcome was all-cause mortality (ACM). Secondary outcomes included non-cancer mortality (NCM), cancer-specific mortality (CSM) and de novo CKD-S Stage 3/4. Multivariable analysis (MVA) was utilised to identify risk factors for outcomes. Kaplan-Meier analysis (KMA) was utilised to evaluate overall (OS), non-cancer (NCS), and cancer-specific survival with respect to CKD-S categories.

RESULTS

We analysed 3239 patients. The mean preoperative and last-follow-up eGFRs were 87.4 and 69.5 mL/min/1.73 m² , respectively. On last follow-up, 57.9% (n = 1876) had no CKD-S, 18.7% (n = 606) had CKD-S 3a, 15.1% (n = 489) had CKD-S 3b and 8.3% (n = 268) had CKD-S 4. On MVA, de novo CKD-S 3b and 4 were independently associated with ACM (hazard ratios [HRs] 1.3-2.1, P = 0.003-0.001) and NCM (HRs 1.5-2.8, P = 0.021-0.001), but not CSM (P = 0.219-0.909); de novo CKD-S 3a was not predictive for any mortality outcomes (P = 0.102-0.81). RN was independently associated with CKD-S 3-4 (HRs 1.78-1.99, P < 0.001-0.035). Comparing no CKD-S, CKD-S 3a, CKD-S 3b and CKD-S 4, KMA demonstrated worsening outcomes with progressive CKD-S stage: 5-year OS 84% vs 78% vs 71% vs 60% (P < 0.001) and 5-year NCS 93% vs 87% vs 83% vs 72% (P < 0.001).

CONCLUSION

Development of CKD-S Stage 3b and 4, but not 3a, was associated with worsened ACM and NCM. The decision to proceed with nephron preservation via PN should be individualised based on oncological risk and risk of functional decline to CKD-S 3b or 4, and not CKD-S 3a.

Brucella aortitis managed with debridement, extra-anatomical bypass, and long-term antimicrobial therapy

OBJECTIVES

This report aims to review the management and outcomes of Brucella-associated mycotic aortic aneurysms.

METHODS

This is a retrospective chart review at a tertiary-level healthcare system. IRB approval was waived per policy.

RESULTS

We describe a case of Brucella aortitis acquired from habitual contact with wild hogs. Clinical presentation included lower back pain and elevated white blood cell count. Diagnosis was confirmed with imaging showing an infrarenal abdominal aortic aneurysm and serology revealing elevated Brucella antibodies titers. The patient was initially managed with endovascular aortic repair and combined oral and intravenous antibiotics therapy. He then underwent explanation and extra-anatomical bypass due to symptomatic periaortic infection and interval development of type I endoleak. The patient was asymptomatic after his final operation at 24 months of follow-up and remained on suppressive oral antibiotic therapy.

CONCLUSIONS

An aortic aneurysm secondary to Brucella is a rare entity. A detailed history of long-term exposure to animals may be a clue to obtain serologic testing. Operative debridement and re-establishing of reliable blood flow combined with long-term antibiotic suppression are the mainstay of treatment.

Management of Lobular Neoplasia Diagnosed by Core Biopsy

Lobular neoplasia (LN) involves proliferative changes within the breast lobules. LN is divided into lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). LCIS can be further subdivided into three subtypes: classic LCIS, pleomorphic LCIS, and LCIS with necrosis (florid type). Because classic LCIS is now considered as a benign etiology, current guidelines recommend close follow-up with imaging versus surgical excision. The goal of our study was to determine if the diagnosis of classic LN on core needle biopsy (CNB) merits surgical excision. This is a retrospective, observational study conducted at Mount Auburn Hospital, Cambridge, MA, from May 17, 2017, through June 30, 2020. We reviewed the data of breast biopsies conducted at our hospital over this period and included patients who were diagnosed with classic LN (LCIS and/or ALH) and excluded patients having any other atypical lesions on CNB. All known cancer patients were excluded. Of the 2707 CNBs performed during the study period, we identified 68 women who were diagnosed with ALH or LCIS on CNB. CNB was performed for an abnormal mammogram in the majority of patients (60; 88%) while 7(10.3%) had an abnormal breast magnetic resonance imaging study (MRI), and 1 had an abnormal ultrasound (US). A total of 58 patients (85%) underwent excisional biopsy, of which 3 (5.2%) showed malignancy, including 2 cases of DCIS and 1 invasive carcinoma. In addition, there was 1 case (1.7%) with pleomorphic LCIS and 11 cases with ADH (15.5%). The management of LN found on core biopsy is evolving, with some advocating surgical excision and others recommending observation. Our data show a change in diagnosis with excisional biopsy in 13 (22.4%) of patients with 2 cases of DCIS, 1 invasive carcinoma, 1 pleomorphic LCIS, and 9 cases of ADH, diagnosed on excisional biopsy. While ALH and classic LCIS are considered benign, the choice of ongoing surveillance versus excisional biopsy should be made with shared decision making with the patient, with consideration of personal and family history, as well as patient preferences.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

P11.65.B GBM AGILE: A global, phase 2/3 adaptive platform trial to evaluate multiple treatment regimens in newly diagnosed and recurrent glioblastoma

Background

GBM AGILE (Glioblastoma Adaptive, Global, Innovative Learning Environment) is a biomarker based, multi-arm, international, seamless Phase 2/3 Response Adaptive Randomization platform trial designed to rapidly identify experimental therapies that improve overall survival and confirm efficacious experimental therapies and associated biomarker signatures to support new drug approvals and registration. It is a collaboration between academic investigators, patient organizations and industry, under the sponsorship of the non-profit organization, Global Coalition for Adaptive Research, to support new drug applications for newly diagnosed and recurrent GBM.

Material and Methods

The primary objective of GBM AGILE is to identify therapies that effectively improve overall survival in patients with newly diagnosed or recurrent GBM. Bayesian response adaptive randomization is used within subtypes of the disease to assign participants to investigational arms based on their performance. Operating under a master protocol, GBM AGILE allows multiple drugs from different pharmaceutical companies to be evaluated simultaneously and/or over time against a common control arm. Based on performance, a drug may graduate and move to a Stage 2 (Phase 3) within the trial, and the totality of the data can be used for a new drug application and registration process. New experimental therapies are added as information about promising new drugs is identified while other therapies are removed as they complete their evaluation. The master protocol/ trial infrastructure includes efficiencies through an adaptive trial design, shared control arm and operational processes such as risk-based monitoring and enhanced remote activities. With its adaptable structure, GBM AGILE has continued trial activation, inclusion of new investigational therapies, and enrollment globally through the challenges of a global pandemic.GBM AGILE provides an efficient mechanism to screen and develop robust information regarding the efficacy of proposed novel therapeutics and associated biomarkers for GBM and to quickly move therapies and biomarkers into clinic. GBM AGILE received initial approval from the United States FDA in April 2019, and in Europe through the Voluntary Harmonization Procedure (VHP) in April, 2021. As of 2022, AGILE has screened over 1000 patients studying multiple investigational treatments. Enrollment rates are 3 to 4 times greater than traditional GBM trials, with active sites averaging 0.75 to 1 patients/site/month.

Currently, there are 41 sites activated in the US, 4 in Canada and 2 in Switzerland and an estimated 24 sites yet to open in Germany, France, Switzerland, Italy and Austria. In addition to the continued expansion in Europe, effort is undergoing to extend the trial to China and Australia as well. Clinical trial information: NCT03970447

OS07.5.A Report from the pooled analysis of the randomized trials NORDIC, NOA-8 and CE.6 on elderly patients with glioblastoma

Background

The majority of patients diagnosed with glioblastoma are over 60 years old. Three randomized trials addressed the roles of radiotherapy (RT) and temozolomide (TMZ) for these patients. Two, the NORDIC and NOA-08 (N&N) compared RT versus TMZ head-to-head, the third, CE.6, randomized between hypofractionated RT and the combination of RT+TMZ. All showed significant benefit for the TMZ arms, especially for patients with MGMT promoter methylated tumors. An ongoing pooled analysis of these three trials focuses on identifying significant baseline prognostic factors and assess their value for predicting outcome in relation to treatment. The aim is improved selection of elderly patients with glioblastoma for their optimal treament; RT alone, TMZ with or without concomitant RT or palliative care.

Methods

The data of two phase 3 studies (N&N) were pooled to build a large dataset and findings are compared to CE.6 trial data. A re-assessment of the clinically most relevant MGMT cut-off is performed. The prognostic value of baseline clinical factors and quality of life scores, determined by the EORTC QLQ-30 and BN-20 questionnaires, are investigated. Data is also analysed to account for a possible impact of sex.

Results

The N&N dataset includes 715 and the comparative dataset (CE.6) 562 patients. Median age for N&N is 71 years and 73 for CE.6. In N&N and CE.6 respectively, 66.2% versus 70.5% underwent resection and 50.9% and 75.3% were on steroids at the time of study inclusion. In N&N, 401 patients received RT alone and 281 in CE.6, while 314 were randomized to TMZ alone in N&N and 281 to concomitant RT and TMZ in CE.6. For N&N MGMT promoter methylation status was successfully determined for 412 (57.6%) and 354 (63.0%) for CE.6. In a first report, patients with the combination of the comorbidities hypertension, diabetes and/or cerebrovascular insult had poorer prognosis when treated with TMZ.

Conclusion

An ongoing pooled analysis of the trials NORDIC, NOA-08 and CE.6 is expected to identify factors that will improve personalized medicine for elderly patients with glioblastoma. Reanalyzed MGMT promoter methylation data and the role of baseline quality of life for outcome will be reported.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

O-147 Genomic analyses in 101,127 UK women show that previously reported monogenic genes are not common causes of premature ovarian insufficiency

Study question

What is the penetrance of variants in previously reported genes for premature ovarian insufficiency (POI) in the general population?

Summary answer

Heterozygous genetic variants in previously reported monogenic genes are not a common, highly penetrant cause of POI.

What is known already

Premature ovarian insufficiency (POI), defined as menopause before 40, has been associated with variants in over 70 genes. However, the evidence to support the causality of individual genetic variants varies between studies. As genomic data becomes more accessible, it is essential to ascertain the penetrance of variants in the absence of family history information. We identified 75 genes associated with POI from the literature, including family segregation studies, consanguineous pedigrees and cohort analyses of whole-exome/targeted sequencing data. Functional evaluation was also available for many of the genes.

Study design, size, duration

We used data from 101,127 females of European ancestry in the UK Biobank, to study the role of previously reported monogenic causal genes on ovarian function. We tested the association of 301 previously reported variants with POI and ANM, plus more than 2.5 million rare variants which were annotated and had not been implicated in POI previously. Genomic variants were tested individually and also combined into a gene burden test.

Participants/materials, setting, methods

Age at natural menopause (ANM) was derived from self-reported questionnaire data from the age at last menstrual period, excluding those with surgical menopause or taking hormone replacement therapy. POI cases were classified as women with ANM under 40 years (N = 2,213). Linked primary care records were used to identify a clinical cohort of POI cases, including primary amenorrhea (N = 113).

Main results and the role of chance

All of the previously reported individual variants we identified in our POI cases were also detected in the control group. Moreover, the gene burden tests were not associated with POI or ANM as a quantitative trait. Our results indicate that autosomal dominant causes of POI are rare; a single predicted loss-of-function (LOF) or non-synonymous genetic variant in one of the previously reported genes is generally not pathogenic.

Limitations, reasons for caution

The penetrance of monogenic disease-causing variants is likely to be lower in population-based cohorts such as UK Biobank than in clinically-ascertained cohorts.

Wider implications of the findings

Heterozygous LOF or non-synonymous variants in previously reported POI genes should be interpreted with caution and are unlikely to cause POI. The findings have implications for clinicians diagnosing causes of POI.

Trial registration number

Not applicable

Command, control and communication (C3) during the COVID-19 pandemic; adapting a military framework to crisis response in a tertiary UK critical care centre

The COVID-19 pandemic of 2020 imposed significant strain on critical care services worldwide. The South London region experienced the largest numbers of critical care admissions in the United Kingdom with King's College Hospital one of the busiest centres. This article outlines, using a descriptive narrative, the significant changes that occurred within King's Critical Care as a result of the pandemic and the decisions that were taken to provide effective co-ordination and control to the expanded service, in part drawing on the military experience of two of the authors. The wider context of crisis and major incident leadership and management is also discussed contrasting different approaches used in civilian and military settings.

Eccrine Carcinoma With an Unknown Primary: Managing Occult Cancer Through Multidisciplinary Tumor Board Collaboration

Eccrine carcinomas are rare cutaneous cancers that tend to be locally aggressive. Here we report a rare case of a mucinous eccrine carcinoma presenting in axillary lymph nodes without an identifiable primary lesion. This is a 69-year-old male with a past medical history of benign prostatic hyperplasia, melanoma, basal cell carcinoma, hypercholesterolemia, hypertension, and arthritis who was found to have an elevated prostate-specific antigen. Transrectal prostate biopsies confirmed adenocarcinoma of the prostate. A chest CT scan performed for further staging of prostate cancer identified new left axillary lymphadenopathy and positron emission tomography (PET)-CT imaging showed moderate fluorodeoxyglucose (FDG) uptake in the lymph nodes of the left axilla and left subpectoral regions. Lymph node tissue obtained by core needle biopsy demonstrated high-grade carcinoma with a nonspecific immunohistochemical profile. Complete left axillary lymphadenectomy was performed, revealing mucinous eccrine carcinoma. He was started on hormonal therapy for prostate cancer and radiation therapy for axillary eccrine carcinoma at the same time. Based on our literature review, this appears to be the first case of eccrine carcinoma in axillary lymph nodes with an unknown primary. This case is further complicated by synchronous primary prostate cancer. After a multidisciplinary tumor board review, it was decided that his axillary disease should be treated as a primary mucinous carcinoma with complete lymphadenectomy followed by localized radiation. The patient had stable disease at the six-month follow-up. Cancers with unknown primary lesions pose unique challenges in disease management. Without established recommendations or guidelines, multidisciplinary discussions and a collaborative approach are needed.

Biomechanical measures of clinician-defined unsteadiness during a forward stepdown task in individuals post-arthroscopy for femoroacetabular impingement syndrome

BACKGROUND

Patients with femoroacetabular impingement syndrome can present with aberrant movement patterns including unsteady balance. Balance training is included in rehabilitation after hip arthroscopy and may improve quality of movement; however, specific biomechanical measures associated with clinician-defined balance impairments are unknown. We aimed to understand these associations as they may inform targeted rehabilitative interventions.

METHODS

The forward stepdown is a clinical test used to evaluate movement quality, including balance. 23 individuals at least one-year post-arthroscopy for femoroacetabular impingement syndrome and 15 healthy comparisons performed the forward stepdown, recorded by 3-dimensional motion capture and 2-dimensional video. Three physical therapists graded the 2-dimensional video for steadiness. Two-way analyses of variance were used to evaluate the interaction of group (post-arthroscopy/healthy comparison) by steadiness (steady/unsteady), for center of pressure medial-lateral excursion, center of pressure path length, and lateral trunk, pelvis, and lower extremity joint excursions.

FINDINGS

Six (26.1%) participants post-arthroscopy and five (33.3%) healthy comparisons were categorized as unsteady. The odds of being categorized as unsteady were not greater for participants post-arthroscopy (P = 0.72). There were no significant interactions; however, participants with clinician-defined unsteady balance, regardless of group, had significantly greater frontal plane trunk excursion, greater hip excursion, and greater center of pressure path length than those with steady balance (P ≤ 0.006).

INTERPRETATION

The odds of being categorized as unsteady were not greater for individuals post-arthroscopy for femoroacetabular impingement syndrome. Clinician-defined unsteadiness was associated with greater frontal plane trunk and hip motion which may be rehabilitation targets to improve balance during a dynamic single-leg task.

Probing Gluon Spin-Momentum Correlations in Transversely Polarized Protons through Midrapidity Isolated Direct Photons in p^{↑}+p Collisions at sqrt[s]=200 GeV

Studying spin-momentum correlations in hadronic collisions offers a glimpse into a three-dimensional picture of proton structure. The transverse single-spin asymmetry for midrapidity isolated direct photons in p^{↑}+p collisions at sqrt[s]=200  GeV is measured with the PHENIX detector at the Relativistic Heavy Ion Collider (RHIC). Because direct photons in particular are produced from the hard scattering and do not interact via the strong force, this measurement is a clean probe of initial-state spin-momentum correlations inside the proton and is in particular sensitive to gluon interference effects within the proton. This is the first time direct photons have been used as a probe of spin-momentum correlations at RHIC. The uncertainties on the results are a 50-fold improvement with respect to those of the one prior measurement for the same observable, from the Fermilab E704 experiment. These results constrain gluon spin-momentum correlations in transversely polarized protons.

A THEORETICAL BASED PHYSIOTHERAPY GOAL SETTING MODEL FOR ANTERIOR CRUCIATE LIGAMENT REHABILITATION

BACKGROUND

Anterior Cruciate Ligament rehabilitation is a lengthy process and requires appropriate goal setting strategies to help optimize patient and athlete outcomes. From a global perspective, ACL injury incidences are continuing to rise, with Australia and the USA having one of the highest incidences of ACL injury rates in the athletic population. In addition, physiotherapists are expected by their professional regulatory body to effectively use goal setting practices.

DESIGN

Theoretical Goal Setting Model consisting of three phases: 1) Pre goal setting phase (empower); 2) goal implementation phase (strive); and 3) goal evaluation phase (attain).

DISCUSSION

This model provides physiotherapists with a useful process so that key aspects of setting goals are considered and incoporporated. This model showcases a necessary path a physiotherapist and patient must journey together in order to enhance rehabilitation outcomes. This model will also advance the  physiotherapists' awareness of the multi-stages of the patients goal desires, intentions and commitment to their rehabilitation.

CONCLUSION

This model is a preliminary attempt to guide both practice, teaching, and research to ensure that goal setting practices in ACL rehabilitation are given an appropriate rehabilitative platform. The next stage is to empirically validate the practical application of the model and how each phase manifests.

Goal setting practices used within anterior cruciate ligament rehabilitation: An exploration of physiotherapists understanding, training and experiences

BACKGROUND

Anterior cruciate ligament (ACL) injuries are a common injury that occurs in both the sporting and non-sporting population. Goal setting is said to be an effective psychological tool within ACL rehabilitation and is commonly used by physiotherapists. To date, literature surrounding goal setting practices is under analysed in relation to qualitative research.

PURPOSE

The central aim of this study was to explore UK physiotherapists understanding, experiences and training towards goal setting practices used in ACL rehabilitation and whether they are effective.

METHOD

Semi-structured interviews involving 24 participants across three specific areas including: National Health Service, elite sport and academia were conducted using an inductive approach. Data analysis included thematic analysis with triangulation and a comprehensive multi-staged analysis process to enhance trustworthiness, whilst respecting ethical considerations.

RESULTS/DISCUSSION

Participants from all three areas of practice tended to use the same approach which was SMART goals. All participants lacked any theoretical understanding of goals but would welcome further training in the field. Participants were missing important aspects of setting goals such as not addressing expectations and underutilising feedback.

CONCLUSION

These findings suggest that a call for more psychological training is clearly warranted in both the physiotherapy curriculum and within post graduate CPD training. Creating a specialist interest group (e.g. physiotherapists interested in psychology) may help share good psychological practices and overall enhance understanding in this field.

Influence of concomitant injuries on post-concussion symptoms after a mild traumatic brain injury - a prospective multicentre cohort study

Objectives: To compare post-concussion symptoms (PCS) and return to normal activities between mild Traumatic Brain Injury (mTBI) patients with or without concomitant injuries at 7-and 90 days post-mTBI.Methods: Design: Sub-analysis of a multicentre prospective cohort study.

PARTICIPANTS AND SETTING

patients with mTBI from 7 Canadian Emergency Departments.

PROCEDURE

Research assistants conducted telephone follow-ups using the Rivermead Postconcussion Symptoms Questionnaire (RPQ) at 7-, 30- and 90 days post-mTBI.

MAIN OUTCOME

Presence of PCS (RPQ: ≥3 symptoms) at 90 days.

SECONDARY OUTCOMES

RPQ score ≥21, prevalence of individual RPQ symptoms and patients' return to normal activities, at 7- and 90-days. Adjusted risk ratios (RR) were calculated.Results: 1725 mTBI patients were included and 1055 (61.1%) had concomitant injuries. Patients with concomitant injuries were at higher risk of having ≥3 symptoms on the RPQ (RR:1.26 [95% CI 1.01-1.58]) at 90 days. They were also at higher risk of experiencing specific symptoms (dizziness, fatigue, headaches and taking longer to think) and of non-return to their normal activities (RR:2.11 [95% CI 1.30-3.45]).Conclusion: Patients with concomitant injuries have slightly more PCS and seemed to be at higher risk of non-return to their normal activities 90 days, compared to patients without concomitant injuries.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

P83 Online Multidisciplinary Review of Point of Care Ultrasound Images During the COVID-19 Pandemic

 

Point-of-care-ultrasound (POCUS) is a valuable diagnostic tool in intensive care. Evaluation of POCUS images acquired in our intensive care unit (ICU) prior to the COVID-19 pandemic had typically been performed solely at the point of care. Where further evaluation was required, cross-sectional thoracic imaging or departmental echocardiography would be requested. Clinicians also had access to ICU ultrasound machines for review of images, or to repeat studies for clarification of findings. However, the nature of the pandemic limited access to ICU to minimise contact with COVID-19.

Objectives

We aimed to develop an online solution for review of POCUS images by the multidisciplinary team (MDT).

Methods

Microsoft Teams was utilised to create a dedicated channel for the MDT to review POCUS images. Images were exported from ultrasound machines used inside our ICU to portable USB drives in standard formats (DICOM or WMV). The portable USB drives were decontaminated prior to transfer outside of the ICU. Anonymised images were uploaded with relevant clinical details to the Teams platform for MDT review.

Results

The online platform provided rapid access to images for review by the MDT. POCUS images from ICU patients with and without COVID-19 were reviewed. MDT review frequently led to a change in patient management. Significant examples included identification of a missed inferior vena cava thrombus leading to initiation of anticoagulation therapy, and rapid expert input for a case of cardiac tamponade.

Conclusion

The use of an online platform allowed our intensive care unit to establish a reliable method for images acquired from point-of-care-ultrasound to be remotely reviewed by an expert multidisciplinary team, consequently improving patient care.

Limitations of Applying Diffusive Gradients in Thin Films to Predict Bioavailability of Metal Mixtures in Aquatic Systems with Unstable Water Chemistries

The present study accessed the use of diffusive gradients in thin film (DGT) as a surrogate for estimating the bioavailability and bioaccumulation of copper (Cu) and zinc (Zn) in a freshwater mussel. We coupled DGTs with mussels and deployed them in a constructed wetland. Water quality parameters were measured for a 4-d period on 3 continuous occasions during 12-d trials in the summer and winter; metal speciation was modeled for each occasion. Higher cumulative rainfall and water turbidity during the summer trial resulted in higher particulate metal concentrations compared to the winter trial. Mussel accumulated metals did not correlate with DGT-measured metals but positively correlated with particulate metals in the summer because filtering particulate food mainly contributed to the bioaccumulation. In contrast, the winter trial suggested a positive correlation between metal bioaccumulation and DGT-measured metals because uptake of dissolved organic matter (DOM) from water mainly contributed to the bioaccumulation, and the labile metal species complexed with DOM generally overlapped with DGT-targeted metals. Though Cu has a higher affinity for organic ligands than Zn, the interactions between Cu and Zn in the mixture did not impede their uptake and bioaccumulation. The deployment duration when DGTs and mussels are coupled to compare metal bioavailability should be no less than 12 d so that mussels have enough time to accumulate contaminants from the environmental media. In summary, DGT is a convenient surrogate for biomonitoring, but it may not fit the real environment such as the aquatic system with unstable water chemistries. Geochemical modeling is good at calculating metal speciation but inferior to DGT in predicting bioavailability and mimicking bioaccumulation. Environ Toxicol Chem 2020;39:2485-2495. © 2020 SETAC.

Feasibility and outcomes of a hepatitis C screening programme in community pharmacies

AIMS

To ascertain the feasibility and outcomes of point-of-care testing for hepatitis C virus (HCV) antibodies in people with risk factors screened in community pharmacies.

METHODS

Ten pharmacies in the Waitematā District Health Board piloted point-of-care antibody HCV screening with consenting participants. Individuals with a positive HCV antibody result had a confirmatory HCV RNA test performed at a local laboratory, with pharmacist follow-up to discuss the result. RNA positive individuals were referred to their general practitioner for further follow-up including antiviral therapy. Number of tests, number of positives and number treated were collected. Pharmacists completed a survey about their experiences.

RESULTS

Of 192 participants, seven (3.6%) had positive tests on screening, four of whom had a positive RNA assay and received HCV medication, and one of whom had a positive RNA assay but has not yet received treatment. Two had negative RNA results. Pharmacist feedback was very positive with most wishing to continue the point-of-care testing service. Most wanted to be able to treat HCV in order to improve linkage to care.

CONCLUSIONS

Pharmacy point-of-care testing with immediate results and pharmacist follow-up of positive results can aid diagnosis of HCV in at-risk populations and help treatment uptake.

Professional consensus on orthodontic risks: What orthodontists should tell their patients

INTRODUCTION

Effective communication of risk is a requisite for valid consent, shared decision-making, and the provision of person-centered care. No agreed standard for the content of discussions with patients about the risks of orthodontic treatment exists. This study aimed to produce a professional consensus recommendation about the risks that should be discussed with patients as part of consent for orthodontic treatment.

METHODS

A serial cross-sectional survey design using a modified electronic Delphi technique was used. Two survey rounds were conducted nationally in the United Kingdom using a custom-made online system. The risks used as the prespecified items scored in the Delphi exercise were identified through a structured literature review. Orthodontists scored treatment risks on a 1-9 scale (1 = not important, 9 = critical to discuss with patients). The consensus that a risk should be discussed as part of consent was predefined as ≥70% orthodontists scoring risk as 7-9 and <15% scoring 1-3.

RESULTS

The electronic Delphi was completed by 237 orthodontists who reached a professional consensus that 10 risks should be discussed as part of consent for orthodontic treatment; demineralization, relapse, resorption, pain, gingivitis, ulceration, appliances breaking, failed tooth movements, treatment duration, and consequences of no treatment.

CONCLUSIONS

A professional orthodontic consensus has been reached that 10 key risks should be discussed with patients as part of consent for orthodontic treatment. The information in this evidence base should be tailored to patients' individual needs and delivered as part of a continuing risk communication process.

Injected human umbilical cord-derived mesenchymal stromal cells do not appear to elicit an inflammatory response in a murine model of osteoarthritis

Objective

This study investigated the effect of hUC-MSCs on osteoarthritis (OA) progression in a xenogeneic model.

Design

Male, 10 week-old C57BL/6 mice underwent sham surgery (n = 15) or partial medial meniscectomy (PMM; n = 76). 5x10⁵ hUC-MSCs (from 3 donors: D1, D2 and D3) were phenotyped via RT-qPCR and immunoprofiling their response to inflammatory stimuli.

They were injected into the mouse joints 3 and 6 weeks post-surgery, harvesting joints at 8 and 12 weeks post-surgery, respectively. A no cell ‘control’ group was also used (n = 29). All knee joints were assessed via micro-computed tomography (μCT) and histology and 10 plasma markers were analysed at 12 weeks.

Results

PMM resulted in cartilage loss and osteophyte formation resembling human OA at both time-points. Injection of one donor's hUC-MSCs into the joint significantly reduced the loss of joint space at 12 weeks post-operatively compared with the PMM control.

This ‘effective’ population of MSCs up-regulated the genes, IDO and TSG6, when stimulated with inflammatory cytokines, more than those from the other two donors.

No evidence of an inflammatory response to the injected cells in any animals, either histologically or with plasma biomarkers, arose.

Conclusion

Beneficial change in a PMM joint was seen with only one hUC-MSC population, perhaps indicating that cell therapy is not appropriate for severely osteoarthritic joints. However, none of the implanted cells appeared to elicit an inflammatory response at the time-points studied. The variability of UC donors suggests some populations may be more therapeutic than others and donor characterisation is essential in developing allogeneic cell therapies.

Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth

BACKGROUND

Prophylactic removal of asymptomatic disease-free impacted wisdom teeth is the surgical removal of wisdom teeth in the absence of symptoms and with no evidence of local disease. Impacted wisdom teeth may be associated with pathological changes, such as pericoronitis, root resorption, gum and alveolar bone disease (periodontitis), caries and the development of cysts and tumours. When surgical removal is performed in older people, the risk of postoperative complications, pain and discomfort is increased. Other reasons to justify prophylactic removal of asymptomatic disease-free impacted third molars have included preventing late lower incisor crowding, preventing damage to adjacent structures such as the second molar or the inferior alveolar nerve, in preparation for orthognathic surgery, in preparation for radiotherapy or during procedures to treat people with trauma to the affected area. Removal of asymptomatic disease-free wisdom teeth is a common procedure, and researchers must determine whether evidence supports this practice. This review is an update of an review originally published in 2005 and previously updated in 2012 and 2016.

OBJECTIVES

To evaluate the effects of removal compared with retention (conservative management) of asymptomatic disease-free impacted wisdom teeth in adolescents and adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 10 May 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2019, Issue 4), MEDLINE Ovid (1946 to 10 May 2019), and Embase Ovid (1980 to 10 May 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov)and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. .

SELECTION CRITERIA

We included randomised controlled trials (RCTs), with no restriction on length of follow-up, comparing removal (or absence) with retention (or presence) of asymptomatic disease-free impacted wisdom teeth in adolescents or adults. We also considered quasi-RCTs and prospective cohort studies for inclusion if investigators measured outcomes with follow-up of five years or longer.

DATA COLLECTION AND ANALYSIS

Eight review authors screened search results and assessed the eligibility of studies for inclusion according to the review inclusion criteria. Eight review authors independently and in duplicate conducted the risk of bias assessments. When information was unclear, we contacted the study authors for additional information.

MAIN RESULTS

This review update includes the same two studies that were identified in our previous version of the review: one RCT with a parallel-group design, which was conducted in a dental hospital setting in the United Kingdom, and one prospective cohort study, which was conducted in the private sector in the USA. Primary outcome No eligible studies in this review reported the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth on health-related quality of life Secondary outcomes We found only low- to very low-certainty evidence of the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth for a limited number of secondary outcome measures. One prospective cohort study, reporting data from a subgroup of 416 healthy male participants, aged 24 to 84 years, compared the effects of the absence (previous removal or agenesis) against the presence of asymptomatic disease-free impacted wisdom teeth on periodontitis and caries associated with the distal aspect of the adjacent second molar during a follow-up period of three to over 25 years. Very low-certainty evidence suggests that the presence of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting the adjacent second molar in the long term. In the same study, which is at serious risk of bias, there is insufficient evidence to demonstrate a difference in caries risk associated with the presence or absence of impacted wisdom teeth. One RCT with 164 randomised and 77 analysed adolescent participants compared the effect of extraction with retention of asymptomatic disease-free impacted wisdom teeth on dimensional changes in the dental arch after five years. Participants (55% female) had previously undergone orthodontic treatment and had 'crowded' wisdom teeth. No evidence from this study, which was at high risk of bias, was found to suggest that removal of asymptomatic disease-free impacted wisdom teeth has a clinically significant effect on dimensional changes in the dental arch. The included studies did not measure any of our other secondary outcomes: costs, other adverse events associated with retention of asymptomatic disease-free impacted wisdom teeth (pericoronitis, root resorption, cyst formation, tumour formation, inflammation/infection) and adverse effects associated with their removal (alveolar osteitis/postoperative infection, nerve injury, damage to adjacent teeth during surgery, bleeding, osteonecrosis related to medication/radiotherapy, inflammation/infection).

AUTHORS' CONCLUSIONS

Insufficient evidence is available to determine whether asymptomatic disease-free impacted wisdom teeth should be removed or retained. Although retention of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting adjacent second molars in the long term, the evidence is very low certainty. Well-designed RCTs investigating long-term and rare effects of retention and removal of asymptomatic disease-free impacted wisdom teeth, in a representative group of individuals, are unlikely to be feasible. In their continuing absence, high quality, long-term prospective cohort studies may provide valuable evidence in the future. Given the current lack of available evidence, patient values should be considered and clinical expertise used to guide shared decision-making with people who have asymptomatic disease-free impacted wisdom teeth. If the decision is made to retain these teeth, clinical assessment at regular intervals to prevent undesirable outcomes is advisable.

Understanding the presence of mental fatigue in English academy soccer players

Research has demonstrated that induced mental fatigue impairs soccer-specific technical, tactical and physical performance in soccer players. The findings are limited by the lack of elite players and low ecological validity of the tasks used to induce mental fatigue, which do not resemble the cognitive demands of soccer. The current study collected survey data from English academy soccer players (n = 256; age groups - U14 - U23), with questions comprising of five themes (descriptors of physical and mental fatigue, travel, education, match-play and fixture congestion). The survey consisted of multiple choice responses, checkboxes and blinded/unblinded (for duration based questions) 0-100 arbitrary unit (AU) slider scales. Listening to music (81.6% of players), using social media (58.3%) and watching videos (34.3%) were the most common pre-match activities. Pre-match subjective mental fatigue was low (18.7±18.8 AU), and most frequently reported at the end of a match (47±26 AU) and remained elevated 24-hours post-match (36±27 AU). Travel (29±24 AU), fixture congestion (44±25 AU) and education (30±26 AU) demonstrated a low to moderate presence of subjective mental fatigue. These findings provide an overview of activities performed by English academy soccer players pre-match, and demonstrate that mental fatigue is experienced as a result of match-play.

A Case of Blunt Trauma-induced ST-elevation Myocardial Infarction Sustained During a Prison Brawl

Myocardial infarction (MI) is a serious and time-sensitive condition. MIs are typically seen in patients with coronary artery disease (CAD) and are caused by the rupture of an atherosclerotic plaque due to factors contributing to plaque instability. However, this case illustrates that plaque rupture can also be caused by blunt trauma to the chest. Considering MI as a possible result of chest trauma may decrease time from presentation to diagnosis and treatment and, therefore, improve outcomes in similar cases, particularly when patients presents unusually or with very few risk factors for MI.

Nuclear Dependence of the Transverse Single-Spin Asymmetry in the Production of Charged Hadrons at Forward Rapidity in Polarized p+p, p+Al, and p+Au Collisions at sqrt[s_{NN}]=200 GeV

We report on the nuclear dependence of transverse single-spin asymmetries (TSSAs) in the production of positively charged hadrons in polarized p^{↑}+p, p^{↑}+Al, and p^{↑}+Au collisions at sqrt[s_{NN}]=200  GeV. The measurements have been performed at forward rapidity (1.4<η<2.4) over the range of transverse momentum (1.8<p_{T}<7.0  GeV/c) and Feynman x (0.1<x_{F}<0.2). We observed positive asymmetries for positively charged hadrons in p^{↑}+p collisions, and significantly reduced asymmetries in p^{↑}+A collisions. These results reveal a nuclear dependence of TSSAs for charged-hadron production in a regime where perturbative techniques are applicable. These results provide new opportunities to use p^{↑}+A collisions as a tool to investigate the rich phenomena behind TSSAs in hadronic collisions and to use TSSAs as a new handle in studying small-system collisions.

The shortened version of the Adolescent Stress Questionnaire (ASQ-S; Sweden): a validation study in United Kingdom adolescents

BACKGROUND

Stress is an important variable of consequence, particularly in adolescence, a period of intense physical and psychological change. The measurement of stress in adolescence has been widely discussed, and a number of versions of the Adolescent Stress Questionnaire (ASQ) have been developed and validated. The present study sought to examine the psychometric properties (model fit, invariance, internal consistency, and construct validity) of the ASQ-S, which was recently developed in a Swedish context.

OBJECTIVE

The study was a secondary analysis of data gathered on the full ASQ. The ASQ-S retained nine of the ten ASQ scales, and a study in Swedish adolescents suggested that the scale was psychometrically valid, gender invariant, and that scores were internally consistent. This is the first study to examine the properties of the ASQ-S in an English-speaking population. Participants were high school children in the UK (N = 610, 61.0% girls) from school year 8 through 12.

RESULTS

Confirmatory factor analysis (CFA) revealed that the nine factor solution fit the data well (χ2s-b(288) = 751.60, CFI = 0.958, TLI = 0.948, SRMR = 0.040, RMSEA = 0.051 [90% CI = 0.047, 0.056]), and that scores were gender, school type (academic versus comprehensive), and school stage (junior versus middle high school) invariant. The nine scales correlated negatively with academic, social, and emotional self-efficacy scores, and self-esteem scores, to varying degrees. Girls reported higher stress levels than boys in six of the nine scales. A regression analysis, adjusted for gender and year in school, suggested that only the stress of peer pressure (negatively) was significantly related to adolescent alcohol use.

CONCLUSIONS

Overall this study suggests that the ASQ-S could be a valid measure of adolescent stress, although concerns remain regarding the convergent validity of scale scores.

Abstract PD8-08: Development of humanized immune DCIS models using patient peripheral blood derived hematopoietic stem cells (CD34+)

Background:

Ductal carcinoma in situ (DCIS) is the most common form of non-invasive breast cancer. To accurately study the natural progression of DCIS lesions in mice, we devised the mouse-intraductal (MIND) animal model, which involves intraductal injection of human DCIS epithelial cells into the mammary ducts of immunocompromised mice. To improve the translational application of the MIND model, we aimed to mimic the natural microenvironment of human DCIS with patient-derived immune cells and assess the role of engrafted immune cells on human DCIS progression. In order to achieve successful engraftment of the entire immune system in mice, we utilized MISTRG mice. These mice were developed by Rongvaux et al., on an immunodeficient (Rag2-/-IL2rγ-/-) background. The genes encoding human M-CSF (M), human IL-3 (I), SIRP1α (S), human thrombopoietin (TPO)(TR), and GM-CSF (G) were knocked into their respective mouse loci. As such, MISTRG mice are highly permissive for human hematopoiesis, supporting the development and function of lymphocytes, monocytes, and natural killer (NK) cells. In contrast, previous studies have used the humanized CD34+ NOD-SCID IL2rγ-/- mice (CD34+NSG), which are unable to support myeloid cell differentiation due to lack of expression of human-specific cytokines. Moreover, prior xenograft studies in the CD34+NSG mice have not used immune cells derived from the same patient as the tumor.

Results:

Human CD34+ cells derived from patients' peripheral blood were expanded ex vivo ˜100-fold using a novel formulation of culture medium. Transplantation of ex vivo expanded CD34+ cells via tail vein injection of MISTRG mice resulted in the successful engraftment of human immune cells as early as 4 weeks following injection. Successful engraftment was confirmed by flow cytometry using human specific antibodies that recognize human leukocytes (anti-CD45), T cells (anti-CD3), B cells (anti-CD20), and myeloid cells (anti-CD33) in spleen, bone marrow, and peripheral blood of MISTRG mice. Once engraftment was confirmed, DCIS epithelial cells from the same DCIS patients or DCIS cell lines were injected intraductally. Recruitment of patient-derived immune cells to the DCIS lesions was confirmed by immunofluorescence using human-specific antibodies that recognize neutrophils (anti-myeloperoxidase), macrophages (anti-CD68), M2-polarized macrophages (anti-c-MAF), natural killer cells (anti-CD56), dendritic cells (anti-CD21), T cells (anti-CD3) and B cells (anti-CD20).

Conclusion:

This model represents the first to enable the study of mechanisms of DCIS progression in a manner that fully represents the heterogeneity of human disease, including the influence of the patients' own immune cells on DCIS progression.

Citation Format: Behbod F, Harper H, Hansford H, Limback D, Hong Y, Elsarraj H, Ricci LR, Fan F, Tawfik O, May L, Cusick T, Inciardi M, Redick M, Gatewood J, Winblad O, Fields TA, Fabian C, Godwin AK, Fields PE, Meierotto R, Perry J. Development of humanized immune DCIS models using patient peripheral blood derived hematopoietic stem cells (CD34+) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-08.